Under the dim hospital light, a midwife, a doctor, a pregnant woman and her mother silently ponder what they should do with a baby that fiercely resists coming out of the womb. The longer the labor, the more dangerous it gets, and it has been almost a full day since the woman arrived here at the hospital. In Bolivia, which has the second-highest maternal mortality rate in South America, such a delay is a mortal threat. But here, in the high Andean plateau, hours from any major hospital, the mother is in very good hands.
The pregnant woman never wanted to go to the hospital. The night before, her mother called Doña Leonarda, the midwife, or partera, to attend the delivery according to traditional Aymara customs. Doña Leonarda was working at the hospital today, so the woman reluctantly came here. Lying on her back, eyes wide open, the mother looks terrified. A young nurse turns to the physician, Dr. Henry Flores, and asks whether she should call the ambulance and take the woman to La Paz for a C-section.
“That would be unwise,” Flores answers in a smooth, low-pitch tone.
It would take more than two hours to get to the capital city and that could be too risky, too late for her. Her pain is increasing and she is already dilated. The doctor measures her contractions and tells the nurse to give the woman an IV solution. “It’s only vitamins,” Doña Leonarda says. But she knows better: they are dripping a painkiller into a plastic bag hanging from a pole – one of the few traces of modernity in this small chamber of the rural hospital. Three deep breaths later Dr. Flores makes a decision.
“Should we try the traditional way?” he asks the partera.
“She is weak but she can do it,” Doña Leonarda answers.
Mother, partera, doctor and nurse place a green mat on the floor of the hospital and gently move the woman over it. She is on her knees, her head on her mother’s hands; Doña Leonarda rolls up the woman’s skirt. It’s going to be a vertical delivery, virtually unheard of in Bolivian hospitals but the traditional method in the Andean region. It’s the way this pregnant woman was born herself, thirty years ago, just like her mother before her, and her grandmother, and so on. Dr. Flores learned the delivery method from the indigenous healers of el altiplano – Bolivia’s Andean plateau – and he is one of the few doctors in the country who is confident enough to try it.
Here on the Bolivian side of el Altiplano, a vast plateau 13,000 feet above sea level, the difference between life and death wears a bowler hat and a rainbow skirt. Far from medical facilities, lacking academic training and marginalized by the public healthcare system, parteras provide the only help that most women get during childbirth. But their efforts are not enough. Hundreds of people die every year during labor, a curse that haunts one of the most vulnerable groups on Earth: rural, poor, indigenous women. Bolivia trails behind almost every other place in the Americas with 206 deaths per 100,000 live births. (The rate in the United States is just fourteen deaths per 100,000.) This revolutionary hospital might be showing the way to put an end to this ongoing tragedy.
Dr. Flores, who runs the local hospital in Patacamaya, approached Leonarda Quispe ten years ago to recruit her for the outpost, even though she had never set foot in medical school and she barely speaks Spanish. Born in a small indigenous Aymara community, Doña Leonarda, as people know her, has been delivering babies since she was twelve. Nobody has ever died under her care, she says “neither a woman nor a newborn,” which might be a record for someone who has attended more than ten thousand childbirths. Seven years ago, Dr. Flores realized the partera was getting more calls than any of his obstetricians and came up with a surprisingly straightforward and inexpensive idea. His plan was to develop a new healthcare system that would attract the local population to the hospital by combining traditional indigenous practices and modern academic knowledge. Should it prove to be successful, it might be adapted and applied everywhere – not just in Bolivia, but around the globe.
In Dr. Flores’ hospital, parteras are welcomed and traditional indigenous doctors have their own offices, alongside skilled surgeons and trained specialists. Doña Leonarda and her husband, Don Vitaliano, are part of the staff; medical doctors like Flores often consult with them. Delivery rooms in Patacamaya’s hospital look like little rural houses: there are kitchens, windows with thick curtains, walls painted in warm colors, wooden furniture and flurry blankets. Nothing is white or shiny. By the pale red cribs, a banner reads “Ususiñ Uta” (birthing chamber), although in the hospital everybody knows these spaces as “intercultural delivery rooms.”
Nearby, in the two-story brick house where Leonarda and Vitaliano live and run their own private practice, there are two bedrooms, plus an examination room filled with jars, syrups and ointments; a couple of tables; some notebooks and a stretcher. As modest as the facility might look, Doña Leonarda and Don Vitaliano attract patients from as far as Chile, Brazil, Argentina, Peru and even Spain.
Hidden in Leonarda’s pollera, a large cotton skirt typical of the Altiplano, a small cellphone insistently buzzes. “Another patient,” she says in Spanish while excusing herself with a gentle gesture of her hand before leaving the room. Wearing a pink sweater and a colorful skirt under a blue apron, she takes her bowler hat off for a second, revealing all of her braided black hair, almost three feet long. Don Vitaliano, a large man with gelled hair, the arms of a builder and the smile of a high-school student, stays behind. Ten years younger than his wife, he is her voice, her aide and her driver. A Honda off-road motorcycle, the engine still warm, waits outside the house. They have just returned from the hospital, where they attended a delivery in the middle of the night.
It’s now seven in the morning. The previous night a woman called from La Paz to ask Doña Leonarda to attend her delivery. Leonarda told her to come here, to her private office in Patacamaya. But when the woman and her mother arrived in the early hours, Don Vitaliano had to convince them to meet his wife at the hospital, where she was still working, rather than at their place. It was a difficult task: they traveled three hours at night to give birth in a traditional environment, with a partera, far from medical doctors and their scary bright-white delivery rooms.
Convincing an indigenous woman to set foot in a hospital is like inviting her to take her life into her hands. “There are some diseases here, in the Altiplano, that urban doctors don’t want to treat,” Don Vitaliano says. Projecting his voice like a Roman orator, he explains the condition of sobreparto, a commonly reported postpartum condition among the Aymaras. Everybody in the rural area has heard about sobreparto and can describe its symptoms: headaches, swelling, fever, fatigue and inability to perform complex tasks. But this malady is not recognized by modern medicine. Therefore, it has no treatment. Indigenous women, however, are extremely scared of it. It attacks them when the rooms are frigid with tiles and metals and when nurses wash them with cold water. “Some mothers prefer to stay at home because they are afraid of getting cold,” Vitaliano says. “When they go to hospitals they are not taken care of properly and, then, they get sick. Sometimes they don’t even speak the same language and doctors yell at them; they cannot talk to anyone and they are terrified.”
At eight a.m. Doña Leonarda jumps on the back of the motorcycle and Don Vitaliano drives back to Patacamaya’s hospital. The partera and her husband quickly cross the waiting room of the hospital, where they meet Dr. Flores. Sporting a white coat and black-framed glasses, he walks from the examination room to the birthing chambers, greeting everyone by name. “How are you today, mamita?” he asks on his way to see his patients. “Don’t forget to tell your daughter to come for the baby’s vaccination.” Flores is a regarded member of the community, trusted both by colleagues and by patients. Five years after he first arrived at Patacamaya, he left for a managerial position in the province’s healthcare system, but ultimately chose to return here.
“Doctors in Bolivia are not getting proper education to understand the cultural and socio-economical conditions of its population,” he says. “They are not flexible at all.” Particularly, he laments that doctors are not familiar with traditional practices here, such as how to attend a vertical birth. Women in the high Andean plateau, like many indigenous woman all over the world, are not used to giving birth while lying on their back. Instead, they prefer to push while squatting or kneeling, something most doctors are not trained to deal with.
It’s time for him to check on the mothers who have been admitted to the hospital. A double door leads Dr. Flores to the first intercultural delivery room. “Good morning,” he says warmly. “How are we feeling? Is everything in order?” A woman in a hat made of llama wool, covered by layers of blankets, blouses, skirts and leggings, lies on one of the beds. Doña Leonarda is standing next to her, checking her pulse while they speak, in Aymara.
“She’s well,” answers the partera. “She’s sleepy and needs to rest. But, before that, we are going to prepare a matecito [tea] for her to drink and stay warm.”
“Good. That’s exactly what she needs,” says the doctor as he approaches the bed. Flores exudes confidence but he moves quietly, giving the impression he is under Doña Leonarda’s supervision. “May I?” he asks before taking the woman’s temperature. She had given birth hours earlier and there might still be some complications.
Dr. Flores follows Doña Leonarda to the next birthing chamber. There are three intercultural delivery rooms in Patacamaya and today each one is occupied. “Kunamastasa, kullaka?” he asks. How are you, sister? Flores picked up rudimentary Aymara during his first years in Patacamaya and using it helps put his patients at ease. “Naya jani walikistwa,” answers the mother. Not very well. She is in pain and Doña Leonarda is here to help. The partera tells the woman to lie down and raises her blouse – she is going to give her a massage.
“I don’t know how she does it,” admits Flores as he looks on, “but I’ve seen several times babies that were upside down, when we were thinking about taking the mother to La Paz for a C-section, and she has managed to turn them around for a perfect delivery.” The pregnant woman says she feels better now, but her grimace says otherwise. She mumbles a few words and Doña Leonarda asks Flores whether he can test the patient’s dilation. Donning latex gloves, the doctor, smiling, starts measuring with his fingers between her legs. She is in her forties, and this is going to be her seventh child. Her husband is sitting on a bed next to his wife’s, but he has said not a word.
For the last hour, Don Vitaliano has been with the woman from La Paz and her mother. They are waiting in the third intercultural room. It’s around nine a.m. now. His role, so far, has been to comfort them. Doña Leonarda introduces Dr. Flores to the woman, who is slowly walking around the beds. The doctor sits next to her mother. He tells her how he works with the partera, helping with vitamins and IVs, if needed, and accompanying her with a nurse to deliver the baby. The physician assures the mother that in this hospital they are going to be “at home.” Doña Leonarda is the last one to leave the room. “It’s going to take long,” she says. “The cervix is not dilated yet.” Though she has difficulty communicating in Spanish, she is precise with medical vocabulary.
The partera and her husband have been working in Patacamaya’s hospital for almost a decade. “Doctors assist me and I assist them,” she says. “We attend together, alongside with nurses and families. We learn from each other.” She has learned how to take out the placenta, what she should do when patients have high blood pressure or when they are bleeding. Whenever she is working alongside a doctor, she helps with massages, takes care of mates and liquids and, sometimes, is in charge of delivering the baby. “I suffered at first because I was scared of doctors. They are well educated but I have all the practical experience. Now nurses ask to attend delivery with me. They want to learn too.”
Bolivia is the only country in the world where interculturality – the relation between two or more cultures – has a high-level executive office. When Evo Morales, the country’s first president with an indigenous background, came to power in 2006, he created the Vice Ministry of Traditional Medicine and Interculturality to improve access to healthcare for indigenous peoples. Its main goal is to tackle maternal mortality rate. Vice minister Alberto Camaqui has been in office since 2010. A somber man, gloomy eyes under a black fedora, Camaqui comes from a rural Quechuan community, the largest ethnic group in the high Andean plateau, just slightly larger than the Aymaran community here. Camaqui’s father-in-law was a traditional doctor and as a kid, he acted as his assistant.
“When I got sick, he called my spirits. To those who are not used to this, it can look like mockery, but I live according to my cosmovision,” he says, using a word that refers to his understanding of the world and its place within the universe. It is a belief that many of his fellow citizens subscribe to. In Patacamaya, when someone is hospitalized, he may blame Pachamama (the goddess of Mother Earth) for his sickness. “Patients won’t mention it to the doctors, because they may be ashamed or they may think that there is nothing they can do about it. That’s the culture shock they go through in the hospitals. To the doctors, illnesses respond to microbes, parasites, viruses…nothing else. But to many indigenous people they also have to do with an unbalanced relation between them and nature. They will finish their medical treatment and still feel that they lack a cure for their soul.”
That culture shock becomes dangerous when women feel more comfortable giving birth in unsafe conditions at home rather than at a hospital. Camaqui started working as a nurse and a cultural facilitator, where he did “a little bit of everything,” even helping during childbirth.
“In the beginning, I was complying with all the official protocols, including those related to delivery,” he says. “Our mothers, our sisters, were used to giving birth in a vertical position. However, doctors didn’t understand what they were supposed to do, since they had studied only Western methods, with gynecological beds. These things scared women in labor who, when they went back home, described their experience. After listening to these stories, many people from the communities didn’t go to the clinics.”
Despite the efforts of the Vice Ministry of Traditional Medicine and Interculturality, funding for rural medicine is limited. Doña Leonarda and Don Vitaliano work for Patacamaya’s hospital, but they do not get paid. The municipal government has the legal authority to set their salary, but there is no room for it in the budget and the law forbids them from charging private patients in public institutions. Therefore, every hour they spend at the hospital means less time taking care of business at their private hospital.
“We had many patients at our place, so when Doctor Henry [Flores] heard about it, he came looking for us,” says Don Vitaliano, over a lunch of ch’arki plates with chuño – llama jerky with freeze-dried potatoes. “He asked for our help.”
Three traditional doctors and three parteras began working under Dr. Flores, with the expectation that the town would eventually pay them a regular wage. They are still fulfilling their part of the agreement, but the local government never delivered. Some families give them gifts after they attend their births – a chicken, some milk, 50 bolivianos ($7.20), but there is no regular fee and they cannot ask for it. Therefore, when a paying client calls, they have to leave the hospital. Sometimes they can convince their paying patients to move to the hospital, like they did today with the woman from La Paz, but there are many others who will refuse to go.
Still, Vitaliano says it’s better than it was before Morales took office, when police went after them and they were arrested for illegal medical practice. “Our brother president,” he says, referring to Morales with the honorific term that many rural Bolivians use, “passed new laws and now we are respected.”
Back at the hospital, the waiting room is teeming with people. The woman who came from La Paz with her mother is pacing up and down one of the rooms. In the other, the laboring woman is still struggling with the pain. “I can’t do it,” she cries in agony. “I won’t be able to make it.” Trying to calm her, Doña Leonarda shushes her gently while removing clothes and blankets. She starts to massage her again when the woman howls. The partera slides swiftly over the bed, no gloves, her hat still on, and sees that the baby is coming. “Empuja, hermanita” – Push, sister! She abruptly throws her hat away and shouts for gloves, but before she can put them on, she already has the baby’s head in her hands. “Push, kullaka, push harder!” The woman yells and whines, tears running down her face.
“We are almost there,” Doña Leonarda says, but then realizes that something is dangerously wrong. The umbilical cord is strangling the baby, rolled up around his neck. The partera turns to us, looking me (Javier) in the eye through the lens of my camera and screams: “doctor, doctor, please! Go find the doctor!” I stop shooting. I cannot move. I am petrified.
Finally overcoming my paralysis, I rush into the corridor to find the doctor. When we get back in the delivery chamber, the baby, wrinkled and red, lies still between his mother’s legs. Doña Leonarda is massaging his back but as soon as Dr. Flores approaches she steps aside. Holding hands with the woman who has just given birth, she looks at how Flores handles the newborn, lifts it up, and scrubs the baby’s chest and his back. Nobody talks. A high-pitched gurgle comes out of the baby. He cries. Doña Leonarda is sweating.
“We have turned traditions into professional practice,” explains Dr. Flores. “Everybody knows that in rural areas women demand a different kind of attention, but for years the medical establishment tried to deny it. In Patacamaya, the staff’s attitude really made a difference.”
So far, Patacamaya’s model has proved a huge success. Since 2009, no woman has died during childbirth at the hopsital, according to Médicos del Mundo, the NGO that helped Dr. Flores start this experiment – highly unusual in the Bolivian plateau. Statistically, it has become the safest place for Aymara women to give birth.
Ten hours later, it’s already dark outside. Doña Leonarda looks at the pregnant woman who came from La Paz. She is finally lying on her bed, after hours and hours of walking up and down the room. She is turning in bed, trying to find a comfortable position, while everyone else waits. Midnight is upon us but the baby doesn’t come.
Under the dim hospital light, a midwife, a doctor, a pregnant woman and her mother silently ponder what they should do with a baby that fiercely resists coming out of the womb. The doctor and the partera already have a solution but they don’t need to rush. The wellbeing of the woman lying in bed is their main concern. There is panting and gasping, crying and yelling, tense muscles and fluids. And, finally, the miracle of life.
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Michele Bertelli, Felix Lill and Javier Sauras have been working for a year on Mothers and Children First, a multimedia story about maternal mortality, gender issues, and indigenous people, funded by the Bill & Melinda Gates Foundation through the Innovation in Development Reporting Grant Program, a media-funding project operated by the European Journalism Center. Visit their Facebook page @MothersAndChildrenDoc.